Bariatric surgery represents one of the most efficient treatments addressing obesity and its associated complications with an increasing trend. Even if the medical benefits for patients are huge, due to weight loss and despite technical improvements in bariatric procedures, it is still associated with diverse types of complications. Most of the complications appear due to nutrient deficiency, as absorption is compromised after surgical anatomy modification. Neurological complications after bariatric surgery are very diverse with an occurrence within days to years after surgery, most frequently in patients with gastrointestinal or surgical complications. Any segment of the nervous system can be affected with distinct types of manifestations ranging from peripheral axonal neuropathy, nerve palsy secondary to compartment syndrome, encephalopathy, and myelopathy, to psychiatric and demyelinating central nervous system diseases. Identifying patients at risk and systematic screening for nutrient deficiency with proper supplementation is essential for preventing neurological complications and lifelong sequelae. In this paper, we present the spectrum of neurological complications reported after bariatric surgery.
Laparoscopic sleeve gastrectomy (LSG) is becoming popular between the bariatric procedures. There are few studies available in the literature about LSG impact on esophageal motility, with debatable results. Technically, it modifies the anatomy of the esophago-gastric junction; it can damage the phreno-esophageal ligament and decrease the lower esophageal sphincter pressure that will predispose to reflux. Gastroesophageal reflux disease (GERD) is already common in obese patients due to frequent hiatal hernia, high intraabdominal pressure, increased transient lower esophageal sphincter relaxations (TLESR), altered esophageal motility and poor esophageal clearance. LSG can worsen gastroesophageal reflux disease, but also the weight loss achieved after it and the decrease of acid production in the small gastric pouch will probably reduce the GERD symptoms. Dysphagia and odynophagia were reported after sleeve gastrectomy, but usually associated with anatomical narrowing of the gastric sleeve, caused by esophageal dismotility or secondary to diabetes mellitus, low tiamine level, the use of opioids and non-steroidal anti-inflammatory drugs, even hypothyroidism. In addition to upper GI tract endoscopy, high-resolution esophageal manometry (HRM) should be required for all patients planning to undergo a LSG, and in the follow-up period according to the contractility pattern.
Gastric antral vascular ectasia (GAVE) is an important cause of gastro-intestinal bleeding. The most common clinical presentation of GAVE is chronic occult bleeding that leads to symptomatic iron deficiency anemia, but some cases could present with acute massive bleeding. Frequently, patients are dependent by iron suplimentation, or in severe cases even blood transfusions. Endoscopic therapy is frequently necessary in acute or chronic blood loss. Over the past several years, treatment for GAVE has continued to evolve as the number of available effective therapeutic interventions has increased. These included: YAG laser, argon plasma coagulation (APC), endoscopic band ligation, cryotherapy and surgical anterectomy. Argon plasma coagulation is the most commonly used technique, but has been associated with several complications like sepsis, post-APC bleeding, gastric outlet obstruction and increased incidence of hyperplastic polyps. Endoscopic band ligation (EBL), a mechanical procedure, has been reported in the past years as an effective salvage therapy for GAVE that is refractory to other approaches, or even as the first line treatment. We present a case of nodular GAVE treated succesfully with endoscopic band ligation after unsuccesufull sessions with argon plasma coagulation.
Colorectal cancer prevalence is increasing worldwide. Modifiable risk factors are responsible for almost 50 % of cases and this could imply a huge potential of preventability. Among these factors the level of physical activity is of paramount importance. Physical activity has a positive impact on health status in general and it decreases the prevalence of various cancers including colorectal cancer. Physical activity decreases the prevalence of benign colorectal adenomas and it prolongs the disease free interval after surgery in colorectal cancer, thus increasing survival. The mechanisms involved are multiple: decreasing bowel transit time, regulating energy balance, decreasing peripheral insulin resistance, decreasing hyperinsulinism, antiinflamatory effects, increasing vitamin D production.
Gut microbiota is a superorganism involved in homeostasis and in pathogenesis. Microbiota composition is influenced by several factors such as: type of birth (cesarean or natural), role of age, role of diet. Pathological consequences of certain type of diet (especially western type of diet) may, in fact, be mediated by gut microbiota alteration. Also few studies have investigated the issue of gut microbiota composition in patients suffering of colorectal cancer, several reports notice relevant differences. Certain pathogenic bacteria in gut microbiota have been extensively studied in relation to their role in colorectal cancer. Thus, Fusobacterium nucleatum, which is abundant in colorectal cancer patient’s colon, may initiate the progression from adenoma to adenocarcinoma. A suggested pattern of oncogenesis in colorectal cancer may be represented by this: dysbiosis-inflammation-oncogenesis. A metanalysis that has been published in 2006 concluded a protective role of probiotics in colorectal cancer and in colonic adenoma.
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Introduction: Our objective is to review current international guidelines for Helicobacter Pylori treatment and our department`s experience in this field. Materials and methods: Helicobacter pylori is a Gram-negative, microaerophilic bacterium that can be found mainly in the gastric mucus or on the inner surface of the gastric epithelium, infecting up to 50% of the population. Colonization with this bacterium is not a disease in itself, but can cause chronic gastritis, peptic ulcer, gastric cancer and MALToma. Because of this, infection with H. pylori continues to be a major healthcare burden, especially in less-developed countries. A multitude of non-invasive tests are available for the diagnosis of Helicobacter pylori infection (blood antibody, stool antigen or urea breath test), but the most reliable method of diagnosis is histological examination from two sites after endoscopic biopsy, combined with either a microbial culture or rapid urease test. Treatment of Helicobacter pylori infection is becoming a challenge, as eradication following standard triple therapy is decreasing worldwide due to increased bacterial resistance against antibiotics, which has led to the development of newer therapies such as the sequential treatment in which a PPI and amoxicillin is given for 5 days followed by a PPI, clarithromycin and metronidazole for another 5 days, or the quadruple therapy based on a PPI, bismuth subcitrate, metronidazole and tetracycline for 10 days. Results and conclusion: H. pylori infection remains one of the most challenging infectious diseases, causing high morbidity and mortality, mainly because none of the actual antibiotic therapies can provide successful eradication.
Chronic liver disease is a late stage of progressive hepatic fibrosis. It consists of functional and structural disruptions in most chronic liver diseases. An accurate diagnosis allows us to establish the degree of fibrosis and the stage of the disease, the prognosis of the patient and to predict a treatment response. Despite the fact that liver biopsy is considered a gold standard, non- invasive methods for diagnosing liver fibrosis have gained more and more importance. Whether we talk about serum biomarkers or imagistic methods from transient elastography to 3-D magnetic resonance elastography, the question remains: are these useful or useless? Serum biomarkers represent blood components that can reflect liver histological changes, thus they can monitor the continuous process of fibrosis. These can be subcategorized in direct (that show extracellular matrix turnover) and indirect markers (that reflect disturbances in the hepatic function). However these markers alone are not as accurate in the staging of fibrosis, only help differentiate patients without or with low grade of fibrosis from those with significant fibrosis and cannot be considered alone in the diagnosis of liver fibrosis. Imagistic methods include: ultrasound-based transient elastography, magnetic resonance elastography (MRE), 2D-shear wave elastography, acoustic radiation impulse imaging (ARFI) and cross sectional imaging, the first being the most used. Using a combination of non-invasive tools allows us to diminish the number of patients in need of liver biopsy. However, the patient must always be informed of the advantages and disadvantages of each method and its limitations.
The burden of colorectal cancer (CRC) is increasing all over the world. The prevalence of diabetes mellitus is increasing. It is estimated that diabetes affects 387 million people worldwide. It is predicted that 552 million people worldwide will develop diabetes by 2030. A large pool of data indicate that DM increases by 2 fold the risk of CRC. This is the reason to firmly suggest the inclusion of DM in the criteria for CRC screening as an important measure to decrease the mortality of this ailment.
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Background: Neuroendocrine tumors of the pancreas (NTP) comprise a unique and relatively rare group of tumors, of which gastrinoma and insulinoma are the most common types. Insulinomas tend to be small, solitary and benign, with surgical resection curable in most cases. Introduction: Insulinomas are localized preoperatively using conventional imaging studies as transabdominal ultrasonography (US), computed tomography (CT), and/or magnetic resonance imaging (MRI). Purpose: Endoscopic ultrasound (EUS) is a valuable tool in the diagnosis of insulinomas. Goals & methods: We performed a retrospective study on 21 patients with insulinoma (6 male and 15 female, 25 to 73 years of age), who were hospitalized and operated on between 2003 and 2012 at “Dr. Carol Davila” Central Military Emergency University Hospital, Bucharest. Results: US view was positive in 10% of patients (2 of 20), that presented proximal location. The sensitivity of CT was unsatisfactory, 21.05% (4 positive results of 19). CT failed to detect liver metastases, but identified nodal metastasis in one patient. MRI was performed in 18 patients and was diagnostic in 11 of them, recording a detection sensitivity of 61.11%, including infra- centimetric tumor size. EUS has a high resolution which allows detection of lesions with very small diameter is safe and minimally invasive. EUS was performed in all patients, being able to identify formations in 17, was inconclusive in 3, showing a diagnosis sensitivity of 81%. Liver metastases were demonstrated in 3 patients, one by US and all 3 by MRI. Conclusions: - CT with intravenous iodinated contrast agent had a poor sensitivity in detecting the primary tumors, was insensitive in detecting liver metastases, but showed metastases in lymph nodes. - MRI has higher sensitivity than CT in detecting primary tumors, including insulinomas with infracentimetric size, and is the imaging test of choice for possible liver metastases. - EUS is the preoperative imaging test of choice.
Introduction: The infection caused by H. pylori appears secondary after a bacterial colonization of the stomach and the initial portion of the small bowel. H. pylori –infected patients can develop gastritis, peptic ulcer, stomach cancer or MALT lymphoma. H. pylori infection is defined by WHO like a type I carcinogen, its role in gastric carcinogenesis being supported by the greatest researchers. Objectives: In this study our purpose was to determine the endoscopic appearances in H. pylori infection quoted in medical literature until now and the frequency of their appearance in our group of interest. Materials and methods: In this study it was made an analytic study in which it was realized a retrospective cohort investigation at the Emergency Central Military and University Hospital “Dr. Carol Davila” Bucharest, gastroenterology branch –endoscopic department between 18.12.2012- 21.08.2013 on 1694 patients between 18 and 92 years old, with the medium age of 55 years old. As a diagnostic method for H. pylori infection we used superior digestive endoscopy during which were taken biopsies and it was made a fast urease test. Results: Regarding the variation of the endoscopic aspects at the population of study, we have found gastritis with all its aspects (which was Sidney classified) in the biggest percentage meaning 59.3% of the cases, followed with a percentage of 18.8% by those without any endoscopic abnormality, and then in 10,33% of the cases we have found peptic ulcer. With a smaller percentage, under 10%, we have found duodenitis at 8.67% of this patients, and finally the most severe lesions represented by gastric cancer and lymphoma were found at 2,7% of the H.pylori infected patients.
Acute mesenteric ischemia (AMI) is a syndrome caused by inadequate blood flow through the mesenteric vessels, resulting in ischemia and eventual gangrene of the bowel wall. AMI may be classified as arterial or venous, non-occlusive or occlusive. The overall prevalence of AMI is 0.1% of all hospital admissions [1]. The exact prevalence of mesenteric venous ischemia (MVT) is not known, because many cases are presumed to be limited in symptomatology and to resolve spontaneously.
Autoimmune cholangitis defines a spectrum of cholestatic liver diseases that are characterized by inflammation of bile ducts and a reasonable response to immunosuppressive therapy. The two most common diseases associated with this term in the literature are: an overlap syndrome of primary biliary cirrhosis and autoimmune hepatitis and a form of hyper IgG4 syndrome (currently associated with autoimmune pancreatitis). Liver biopsy is mandatory for the diagnosis. There are, whatsoever, in clinical practice, many cases that do not meet current diagnostic criteria but that have a good response to corticosteroid treatment.
Chronic pancreatitis is characterised by progressive and irreversible damage of the pancreatic parenchyma and ductal system, which leads to chronic pain, loss of endocrine and exocrine functions. Clinically, pancreatic exocrine insufficiency becomes apparent only after 90% of the parenchima has been lost. Despite the simple definition, diagnosing chronic pancreatitis remains a challenge, especially for early stage disease. Because pancreatic function tests can be normal until late stages and have significant limitations, there is an incresing interest in the role of imaging techniques for the diagnosis of chronic pancreatitis. In this article we review the utility and accuracy of different imaging methods in the diagnosis of chronic pancreatitis, focusing on the role of advanced imaging (magnetic resonance imaging, endoscopic retrograde cholangiopancreatography and endoscopic ultrasound).
Nonalcoholic fatty liver disease (NAFLD) is defined as the presence of fat in the liver (hepatic steatosis) either on imaging or on liver histology only after the exclusion of secondary causes of fat accumulation in the liver (e.g. high alcohol drinking, drugs and other medical ailments). Considering the fact that there are many causes of hepatic steatosis, the term NAFLD is reserved for the liver disease that is predominantly associated with obesity and metabolic syndrome. The presence of inflammation and cell injury defines steatohepatitis (NASH) which has the potential to evolve into cirrhosis and hepatocarcinoma, being, therefore, the stage of NAFLD most amenable to treatment. Among the treatments available, the most important are: weight loss, vitamin E and, last but not least, probiotics.
Background: COVID-19, declared a Public Health Emergency of International Concern, affected hospital operations by increasing the number of patients presenting to hospitals, the necessity to control infections, and the shortage of staff. Through our study, we evaluated the quality and quantity of care and how these changes affected patient experience and outcomes, and we identified actionable methods in order to prepare for the future. Methods: We analyzed data between 2020 and the first half of 2023 from a Romanian tertiary military hospital using patient-reported experience surveys and operational indicators (readmissions, postoperative complications). Associations were assessed using Pearson and Spearman correlation coefficients. We then benchmarked against an ideal surge-ready hospital using a 0-1 Composite Risk Index (CRI) that integrates occupancy, adverse-event density, flow reliability, and readmissions. Results: Overall satisfaction was strongly influenced by satisfaction with medical care (p < 0.001). Higher overall satisfaction was associated with fewer readmissions. Benchmarking showed the highest risk in the ICU, intermediate in Surgery and Internal Medicine, moderate in the ED, and the lowest in the Ambulatory. Satisfaction was highest in the initial period of the COVID-19 pandemic, dropped in 2022, and showed partial recovery at the end of this period. Conclusions: Quality of care is a critical measure of hospital performance, especially in the context of the COVID-19 pandemic. Patient feedback revealed areas of good practice and also the limits of the system, influenced by the burden of multisystem disease and limited resources. Post-COVID-19 disability outcomes are strongly influenced by the quality and continuity of care. Systematic use of patient- reported outcomes, standardized evaluation, and adaptive rehabilitation is essential to preserve the quality of care and reduce long- term functional impairment.
Introduction: Heart rate variability (HRV) reflects autonomic nervous system (ANS) activity and emotional responsiveness. Music influences autonomic regulation through the heart–brain axis, yet sex-specific autonomic responses to different musical genres remain insufficiently characterized. Materials and methods: HRV parameters were recorded in 24 healthy young adults (17 females, 7 males; mean age 27.04 ± 1.97 years) at rest and during exposure to six musical genres: Baroque, Jazz, Heavy Metal, Romantic, Traditional Romanian, and Ambient. Time-domain and frequency-domain HRV parameters, including low frequency (LF), high frequency (HF), normalized LF (nLF), normalized HF(nHF), LF/HF ratio, and normalized coherence (NCoh), were analyzed. Anxiety was assessed using the Hospital Anxiety and Depression Scale (HADS).Results: Heart rate did not differ between rest and musical sessions. In contrast, significant changes were observed in HRV parameters, particularly in the frequency domain. Compared with rest, nLF and LF/HF increased, and nHF decreased during all musical sessions, with more pronounced effects in males. Differences between musical genres were limited, whereas sex-related differences were consistent across sessions. rMSSD and HF were strongly correlated in all conditions except Jazz in males. LF/HF correlated directly with nLF and NCoh and inversely with nHF. Conclusion: Music modulates cardiac autonomic balance without altering heart rate. Autonomic responses are predominantly sex-dependent rather than genre-dependent, underscoring the importance of sex-specific analysis in studies investigating music-induced autonomic modulation.
